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Botulinum toxin (Botox) injections for spasmodic dysphonia & tremor

Updated: Nov 6, 2020

Alright, let's talk Botulinum toxin injections (say that five times fast), otherwise known as Botox. Receiving botulinum toxin injections as a patient can be anxiety producing, scary, and confusing. So let's talk some education and facts.

Botulinum toxin injections are used for those with spasmodic dysphonia or essential tremor of the voice.

Botox for spasmodic dysphonia and tremor

Botox injections are currently the preferred treatment for SD and are considered the "gold standard" of care. Botox is injected into the laryngeal muscles (thyroarytenoid for AD and posterior cricoarytenoid for AB, either bilaterally or unilaterally). Botox serves as an agent to block nerve signals at the muscle receptor site. More simply, Botox temporarily “paralyzes” the muscle to minimize or eliminate the involuntary spasms. This leads to only a temporary improvement, because the nerve endings eventually regenerate and the muscles resume their contraction pattern. Thus, the need for re-injections. The length of benefit varies from patient to patient; however, the average length is three to four months. Patients may choose to elongate the length of benefit by increasing the dosage of the injection, however this typically also results in a longer side effect period. Discussions with the otolaryngologist and speech pathologist can help to determine optimal dose.

*It is important to note that botox is generally less effective for tremor as well as less effective for ABSD than it is for ADSD. If you have tremor along with ADSD botox may help decrease symptoms of ADSD but some symptoms of tremor may remain. If you have Muscle Tension Dysphonia on top of ADSD, ABSD, or tremor, you may need voice therapy along with botox to eliminated the patterns of muscle tension.

Botox injections- how they work

There are two main methods of injection; Through EMG or through with a scope in your nose

With EMG:

An EMG machine detects muscle activity. Typically electrode sensors (like sticky pads with wires) are attached to several places on your chest/neck. These sensors allow the machine to detect levels of muscle activity. this machine is attached to the needle that the doctor uses to inject the botox and allows him/her to tell how much muscle activity is associated with the area that his/her needle is in. The idea is for the physician to find the place of greatest muscle activity to inject botox into. Again, the muscles of interest here are the TA muscle for ADSD typically or the PCA muscle for ABSD (posterior muscle).

Your physician will use needle to inject numbing medication through your neck. He/she will then insert the botox with a needle. Once the needle is in the correct muscle, the doctor will ask you to say “eee” or sniff. You will hear static coming from the EMG machine when the physician is in the correct spot of the muscle. When the doctor locates the area of greatest muscle activity, he or she will inject the Botox.

With a flexible scope:

The doctor will spray lidocaine and afrin into your nose. He/she will then insert the scope into your nose. He/she will inject the muscles in your neck with the scope in your nose to assess the right area for injection.

For ADSD: The botulinum toxin is injected unilaterally or bilaterally in the same visit. Average doses hover around 1.25 units each side.

For ABSD: only one side is injected at a time due to concerns with breathing. The patient will return several weeks after the first side is injected for the other side to be injected. ABSD is a harder injection due to the fact that the physician needs to get to the posterior muscle (in the back). Doses are typically much higher for ABSD due to the increased muscle size of the PCA.

What should I expect with Botox injections?

Your voice will typically not change immediately after the injection. Some may experience an immediate voice change prior to the botox taking effect, as the sensory signals are altered with the injection and there is an immediate inflammatory effect. Within 24-72 hours of the injection, you should develop a weak and breathy voice quality that may sound high pitched like Minnie Mouse. This will last up potentially up to 2 weeks (or longer if you received a high dose for you). The stronger the dose received, typically the longer the side effect period will be. If you received a strong dose or if you are "sensitive" to botox you may experience some longer duration of side effects. Your voice should gradually become stronger, the amount of effort required to speak should lessen and you should achieve a more fluent or more "normal" voice quality. Note, this is not an exact science and the voice should not be expected to be entirely "normal" as it was pre-botox necessarily. As the BoTox wears off, the spasms will gradually return. We recommend you return for another injection when the symptoms start to return.

No change after the botox injection?

If your voice does not change or get weaker/breathier after 72 hours the Botox may not have hit the correct spot in the muscle, which occasionally occurs. If this happens, contact your doctor to be scheduled for a reinjection.

Botox dosing:

The dosage of Botox injected and type (unilateral or bilateral) differs for each patient. It may require several injections to establish the optimal individualized Botox dose for you, as optimal dosage for each patient is different. Optimal dosage is a balance of duration of injection side effects/breathiness and duration of clear voice. Some may prefer to have a stronger dosage with a longer period of breathiness after the injection and a longer duration of optimal voice (requiring fewer shots per year), while others may prefer to minimize the side effect duration to opt for shorter lasting, more frequent injections. Two different individuals may also have different results from the same dosage (due to differing anatomy, neurology, severity of SD etc.) so initial dosages must be trialed and tailored to fit the individual’s needs. Individuals may choose to time injections around important speaking events (i.e. presentations, weddings). Unilateral injections may offer a good option for some individuals desiring less side effects.

Things to know about following your botox injections

You typically can speak and eat and drink as normally following the injection. During the weak period, you may experience that your voice tires out very quickly. Avoid pushing through this and avoid straining your voice. Rest when your voice feels tired. Avoid speaking in loud environments, shouting, or yelling. Use a voice amplifier during this time if you have one. Avoid coughing and throat clearing, which can cause trauma to the voice during this time.

Are there any side effects of Botox injections?

An individual should never experience significant pain during or after the injection but may experience some soreness at the spot of injection the day of the injection and possibly for 1-2 days after. This should resolve quickly after the injection. Swallowing problems (i.e., coughing with eating and drinking, or food/liquid “slipping down the wrong pipe”) occur in some patients after receiving Botox, as the vocal folds serve to produce voice but also as a protector of our airway during swallowing. Weakening of the muscles results in less closure of the vocal folds during swallowing with a potential risk of aspiration of thin liquids or foods. Thin liquid (i.e., water, tea, coffee) is the consistency that commonly gives patients the most difficulty. If you do experience swallowing problems, they should resolve as your voice strengthens and progresses to the near-normal/normal period. See below for swallowing recommendations during this time.

What can I do to manage any swallowing difficulty?

1. Drink and eat more slowly. Be mindful of each swallow. Avoid distractions when drinking/eating.

2. Take small sips and small bites. Chew well.

3. Eat and drink remaining upright completely.

4. Use a Contigo cup to more easily control the sip size. Avoid straws.

5. Chin Tuck: Take a sip/bite, tuck chin downwards, and swallow.

6. Use the Supraglottic Swallow compensatory technique, as needed:

-Hold your breath

-Take a sip and swallow

-Clear your throat

- Swallow again

7. Choose thicker liquids (i.e, nectar juice, milkshakes, creamy soups)

8. Avoid things with “mixed” consistencies (i.e. cereal with milk, thin soups with vegetables)

What can I do to manage my breathy or weak voice during the side effect period?

Use any resonant and easy voicing strategies you may have learned from your speech language pathologist. Straw phonation and vocal "warm-ups" may be helpful during this time. A voice amplifier may be helpful for some individuals during the weakened stage. To avoid amplifying the side effects, avoid straining and pushing your voice and try to speak with more ease and breath. You may overarticulate sounds at your lips to be heard more clearly and use non-verbal communication when needed (writing, whiteboard, text to speech etc.).

What should I do prior to my next appointment?

Complete a voice journal at each day post injection for two weeks and once weekly thereafter. It is important that you record your results in your Botox log, so we know whether an adjustment to your dosage is necessary for you to achieve the best results.

You can track the following on a scale of 0-10:

  • Breathiness (0-10)

  • Roughness (0-10)

  • Weakness/low volume (0-10)

  • Change in pitch (0-10), indicate High or Low

  • Strain (0-10)

  • Difficulty swallowing (0-10)

  • Ease of voice production (0-10)

  • Breaks (0-10)

Want to talk in more detail about your specific botox needs? Have fears, anxiety or questions surrounding botox? Don't know if botox is right for you?

We offer botox counseling and education. Contact me at for a free consult to learn more!

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